Government of the Republic of Zambia Ministry of Finance and National Planning and Ministry of Health and the Government of the United States of America to Support Implementation of the Zambian National Response to HIV And AIDS From 2011-2015

ANCSS

Antenatal Care Surveillance Survey

ART

Anti-retroviral Therapy

ARV

Anti-retroviral Drugs

BCC

Behavior Change Communication

BMGF

Bill & Melinda Gates Foundation

CBC

Community-based Care

CBO

Community-based Organization

CSO

Civil Society Organization

DFID

United Kingdom, Department for International Development

FNDP

Fifth National Development Plan

GBV

Gender-based Violence

GRZ

Government of the Republic of Zambia

HBC

Home-based Care

HMIS

Health Management Information System

IEC

Information, Education, and Communication

ILO

International Labor Organization

JARJAPR

Joint Annual Review
Joint Annual Program Review

JFA

Joint Financing Arrangement

MC

Male Circumcision

MCP

Multiple and Concurrent Partnerships

MDG

Millennium Development Goal

M&E

Monitoring and Evaluation

MNCH

Maternal, Newborn and Child Health

MOH

Ministry of Health

MTCT

Mother-to-Child Transmission

NAC

National HIV/AIDS/STI/TB Council

NASF

National AIDS Strategic Framework

NHSP

National Health Strategic Plan

NGO

Non-Governmental Organization

OI

Opportunistic Infection

OVC

Orphans and Vulnerable Children

PEP

Post Exposure Prophylaxis

PEPFAR

President's Emergency Plan for AIDS Relief

PLHA

People Living with HIV and AIDS

PMTCT

Prevention of Mother to Child Transmission

PPP

Public Private Partnership

PWP

Prevention with Positives

RHSNDP

Reproductive Health
Sixth National Development Plan

STI

Sexually Transmitted Infection

SWAp

Sector Wide Approach

TB

Tuberculosis

TCTTI

Testing and Counseling
Transfusion Transmissable Infection

UNAIDS

Joint United Nations Program on AIDS

UNICEF

United Nations Children’s Fund

UNGASS

UN General Assembly Special Session on HIV and AIDS

UNFPA

United Nations Population Fund

USG

United States Government

WHO

World Health Organization

ZDHS

Zambia Demographic and Health Survey

ZHDR

Zambia Human Development Report

Partnership Framework

This Partnership Framework is signed by the Government of the Republic of Zambia (GRZ) through the Ministry of Finance and National Planning (MOFNP) and the Ministry of Health (MOH), together referred to as the ‘Government’ and the United States Government (USG), to confirm commitment to support the national HIV and AIDS multisectoral response from 2011-2015. The GRZ and the USG together are referred to as the ‘Partners’.

Whereas

1. In Zambia, current HIV prevalence is 14.3 percent among adults aged 15-49 and it is estimated that there are over one million Zambians living with HIV and AIDS.

3. While access to treatment has improved, over 75,000 Zambians die from HIV annually.

4. Zambia is home to over 800,000 OVC 0-17 years of age due to AIDS.[1] Four in ten children under age 18 are not living with both parents; and 15 percent of children under age 18 are orphaned—one or both parents are dead.

5. Efforts in Zambia to scale up access to Antiretroviral Therapy (ART) have led to an increase in the number of HIV positive-eligible clients accessing Antiretroviral drugs (ARVs) from approximately 3000 in 2004 to 285,000 in 2009.

6. Prevention programs have also been scaled up including the number of testing and counseling (TC) centers, and prevention of mother to child transmission (PMTCT) centers. Despite these prevention efforts, however, the number of new infections remains high with an estimated 82,681 adults newly infected in 2009.

7. The GRZ recognizes and values the technical and financial support received from donors and Cooperating Partners for the national HIV and AIDS program.

8. The USG via the President’s Emergency Plan for AIDS Relief (PEPFAR) is the largest bilateral donor supporting the national HIV and AIDS program in Zambia. Through PEPFAR, Zambia received more than $1 billion between Fiscal Year (FY) 2004 and FY 2009 to support comprehensive HIV/AIDS prevention, treatment and care programs.

9. Zambia's achievement of national targets and contributions to PEPFAR’s global results include the placement of nearly 270,000 men, women and children on ART; providing care to almost 370,000 people affected by HIV, and applying proven PMTCT interventions to over 30,000 HIV positive pregnant women as well as providing support to over 400,000 orphans and vulnerable children (OVC).

10. In 2008, the U.S. Congress reauthorized PEPFAR for an additional five years (2009-2013). In reauthorizing PEPFAR, the U.S. Congress sought to build upon past investments to further support health systems, foster greater country ownership of HIV and AIDS activities and identify means to institutionalize, and thereby sustain, country-led responses.

11. PEPFAR reauthorization called for the development of Partnership Frameworks that lay out a five-year coordinated response for HIV and AIDS programming among PEPFAR country governments, the USG and other partners.

12. Partnership Frameworks are designed to support governments to realize health sector and HIV and AIDS goals and objectives through technical assistance and support for service delivery, policy reform and coordinated financial commitments; and to promote government ownership and capacity for a sustainable response to the HIV and AIDS epidemic.

13. Each Partnership Framework is complemented by a Partnership Framework Implementation Plan that details more specifically the five-year objectives, contributions and targets.

14. PEPFAR is authorized by the U.S. Congress until the end of 2013; therefore, PEPFAR Zambia activities and support for the period 2014-2015 are subject to further reauthorization and availability of funds.

NOW THEREFORE all Partners recognize:

1. Interpretation

1.1 This Partnership Framework is not a legally binding document and does not create any rights or obligations under international law, but reflects joint commitment to increased partnership for the implementation of the Partnership Framework.

1.2 The purpose of the Partnership Framework is to present jointly determined terms and procedures for support to the national response to HIV and AIDS in Zambia; and to serve as a coordinating framework for consultation between the GRZ and USG for the articulation of joint objectives, program prioritization and planning, joint performance reviews, common management arrangements, reporting and audits—see Appendix 1 Background.

2. Definitions

2.1 The Partnership Framework is directly aligned with the National AIDS Strategic Framework 2011-2015 (NASF 2011-2015) and the National Health Strategic Plan 2011-2015 (NHSP 2011-2015) and is intended to be implemented within GRZ processes and systems as well as with selected private sector partners and civil society organizations (CSOs).

2.2 The vision of the five year NASF 2011-2015 and the Partnership Framework is “A nation free from the threat of HIV and AIDS.”

2.3 The MOFNP, the MOH and the National HIV/AIDS/STD/TB Council (NAC) are the arms of the GRZ that are involved in the development, management, monitoring and coordination of the national response and thus the Partnership Framework.

2.4 The "Three Ones" principles are defined as One National Strategy, which is the NASF 2011-2015; One National Authority, which is the NAC; and One National Monitoring and Evaluation (M&E) System. While the Partnership Framework plans to operate under independent financing arrangements for USG foreign assistance, it is to be optimally integrated within the overall HIV resource envelope and aligned with other Cooperating Partner contributions in a transparent fashion.

2.5 Cooperating Partners are bilateral and multilateral organizations working in partnership together and with the GRZ to provide financial, technical and other assistance to support and improve the national HIV and AIDS response.

3. Overarching Objectives

3.1 This Partnership Framework represents enhanced engagement by the GRZ, with support from the USG and other partners, to turn the tide of HIV in Zambia, and to create a nation free from the threat of HIV and AIDS. It also represents an unprecedented level of coordination and collaboration between the GRZ, USG, and other partners in jointly setting programmatic priorities, articulating individual and shared objectives, and in undertaking strategic planning for the next five years of the Zambian national HIV and AIDS response.

3.2 The overarching purpose of this Partnership Framework is to provide an outline for cooperation to strengthen the capacity for a well coordinated and sustainably managed HIV and AIDS multisectoral response. Objectives 1, 2, 3 and 5 for the Partnership Framework are directly from the NASF 2011-2015. Objective 4 is drawn from the NHSP 2011-2015 in order to provide overall health systems support. Program investments are designed to target the drivers of the epidemic to achieve Zambia’s priorities to reduce the threat of HIV and AIDS.

4. Partnership Framework Objectives

To accelerate and intensify prevention in order to reduce the annual rate of new HIV infections;

To accelerate the provision of universal access to comprehensive and quality treatment, care and support for people living with HIV and AIDS (PLHA), their caregivers and their families, including services for tuberculosis (TB), sexually transmitted infections (STIs) and other opportunistic infections (OIs);

To mitigate the socio-economic impact of HIV and AIDS especially among the most vulnerable groups, orphans and vulnerable children (OVC), PLHA and their caregivers and families;

To strengthen the systems which underpin Zambia’s response to HIV and AIDS; and

To strengthen the capacity for a well coordinated and sustainably managed HIV and AIDS multisectoral response.

5. GRZ Vision, Goal and National Level Impact Results

5.1 The Partnership Framework is further premised upon the GRZ’s high-level vision, an associated goal and national impact level results for Zambia’s response to HIV and AIDS-- see Appendix 2 The HIV Epidemic in Zambia. USG investments in Zambia are designed to contribute to the GRZ’s long-term attainment of the goal and national level impact results.

Vision: A nation free from the threat of HIV and AIDS

Goal: Reduce new HIV infections by 50 percent while scaling up treatment, care and support

National Impact Level Results:

Level

Description of Impact Level Results

National

Zambia Human Development Index (HDI) is improved from 0.434[2] in 2005 to 0.450 by 2015[3]

Prevention

By 2015, the rate of annual HIV new infections is reduced from 1.6% to below 0.8% (82,000 annual new infections to 40,000) by 2015

The number of infants born of HIV positive mothers who are infected is reduced to less than 5%[4] by 2015

Treatment, Care and Support

More PLHA live longer: PLHA who are alive at 36 months after initiation of antiretroviral therapy is increased to 85% by 2015[5]

Impact Mitigation

Fewer households are vulnerable: The number of vulnerable households is reduced by 50% by 2015

Response management

The total NASF service coverage targets (output level results) met in all four pillars is increased to 50% by 2013 and 90% by 2015

6. Partnership Framework Implementation Plan

Success of the Partnership Framework is dependent on the development of an effective Implementation Plan that is collectively and collaboratively executed by the GRZ, the USG, and other partners. The Implementation Plan is to be derived from the goals and objectives outlined within the Partnership Framework and the National Multisectoral HIV and AIDS Programme Operational Plan 2011-2013 (NOP 2011-2013). Similarly, as with the Partnership Framework, the Implementation Plan is to be fully aligned with the NASF 2011-2015 and NHSP 2011-2015, and other relevant strategies and documents available to guide priority setting and associated resource allocations—see Appendix 3 Developing the Partnership Framework Implementation Plan.

7. General Principles of Partnership

7.1 In implementing this Partnership Framework, the GRZ and the USG dedicate themselves to the following principles:

High-level government engagement, national leadership, and continued ownership of the response by the government and people of Zambia;

Continued collection and application of the best available data and practices to inform and improve HIV policies and programming;

Enhanced focus on the sustainability of all investments and interventions with the clear intention of the USG to transition resources, ownership and accountability to local institutions;

Support for decentralization and the integration of health and other essential HIV services into existing governmental and non-governmental (NGO) structures with recognition of the key roles played by civil society and private sector organizations;

Meaningful involvement of PLHA, their communities and civil society in program development, implementation, and evaluation; and

Increased focus on a human rights-based approach to reduce stigma, discrimination, and the disproportionate impact of HIV on women, girls and other vulnerable groups.

In its second phase, PEPFAR maintains the goals of increasing access to ART; providing care to people affected by HIV, including OVC; and preventing new infections. In addition, the next phase of PEPFAR places greater emphasis on strengthening national health systems, including the health care workforce. It also focuses on enhancing partnerships with governments to strengthen country ownership and build capacity for a long-term and sustainable nationally-led response—see Appendix 4 The National Response.

7.2 Financial Principles

In addition to the principles above, the Partners affirm the importance of the following financial principles:

A. Transparency in resource allocation and expenditures;

B. Increases in USG resources for anti-retroviral drugs are predicated on increases in GRZ investments for ARVs;

C. The importance of continued, coordinated capacity development efforts to improve public administration capacity, particularly in public financial management;

D. To collect and share optimal detail on planned annual financial commitments to HIV from all sources so that (1) the total resource envelope for the national response is well understood and optimally integrated, and (2) the proportion of the total response underwritten by GRZ increases on an annual basis for the term of the Partnership Framework;

E. Managing resources to achieve national and Partnership Framework results while reducing Zambia’s reliance on foreign aid over time;

F. Recognizing that financial and material resources from the GRZ, USG and other Cooperating Partner resources are limited, prioritization is necessary to achieve the most durable public health impact from the available resources, and that planned investments are subject to the availability of funds;

G. Recognition that achievement of national HIV and AIDS goals requires resource flows beyond the ability of any one partner, and that constraints on availability of funding from either Government or from other key partners could lead to a review and revision of goals;

H. Where U.S. assistance is provided directly to the GRZ under this Partnership Framework, GRZ is expected to provide partner country cost sharing under U.S. foreign assistance programs. Details regarding the GRZ’s financial and/or in-kind contributions to programs under this Partnership Framework are to be provided in the Partnership Framework Implementation Plan; [6] and

I. While the U.S. Government’s main modality for delivering development assistance is project support, U.S. Government investments in Zambia are to be transparent and based on Zambian health sector and HIV and AIDS priorities, and are to support the principles of the “Three Ones.”

8. Partner Roles and Responsibilities

8.1 Roles and expected contributions of the Partners to this Partnership Framework fall into three broad categories: (1) national leadership and public systems, (2) program implementation, and (3) health and other service delivery systems strengthening including supporting an optimal policy and resource environment.

8.2 National leadership for a multi-sector response to HIV and AIDS is the primary mandate of the GRZ. Government leadership is a key element of this Partnership Framework. The USG and other cooperating partners are to work with the GRZ to prioritize investments as per the objectives. The GRZ, via the MOH and the NAC, is to mobilize other ministries to support the national HIV and AIDS program and outline required resources to ensure full implementation of the program. Through this Partnership Framework the USG explicitly supports GRZ leadership in the health and development sector in the country.

8.3 Program implementation is to be led by the GRZ with the majority of health service provision related to HIV being carried out in public facilities. Specific service delivery areas that are a focus for program implementation are prevention of new infections, treatment care and support, impact mitigation (OVC, vulnerable households, communities and individuals), and response management (policy, coordination and management, gender, M&E and research). Through requirements as laid out by U.S. Congressional earmarks, PEPFAR resources are to be employed with the GRZ to prioritize investments in each of these service delivery areas. For example, currently 10 percent of PEPFAR resources annually are mandated by the U.S. Congress for OVC services.

A key feature of future program implementation is to be the development of public-private partnerships (PPPs) in order to enhance the national and local framework for action. These partnerships are to include work-based HIV and AIDS programming as well as linking private sector resources to community-driven priorities for the prevention of HIV and management of AIDS. Given that HIV in Zambia is most predominant among urban, educated men and women, the GRZ and other partners must think and act creatively to target this particular population. While the private sector, including civil society organizations, expands services to more vulnerable populations, it is also a potential platform for reaching more educated, wealthier Zambians.

The GRZ is to lead and (in partnership with other donors) resource the systems strengthening agenda as laid out in the NHSP 2011-2015. The USG is committed to supporting these efforts as they are critical to ensuring a long-term and sustainable national response. Leadership and political will for systems strengthening are to be provided by the GRZ. Building the necessary health systems and the capacity of Zambians to more effectively plan, manage and monitor HIV and AIDS programs are central to program implementation as outlined in this Partnership Framework. As emphasized in the NASF 2011-2015, the GRZ is committed to reducing the rate of new HIV infections by 2015 and beyond. Sustained reductions in HIV infections can only happen within the framework of a fully functional health system managed by Zambians who have the requisite competence and resources (technical, programmatic and financial). Systems within this Partnership Framework include but are not limited to: health care provider training, health management information systems (HMIS) and M&E; supply chain and commodity procurement and management; clinical services and referrals; laboratory; and community based services and networks.

Through PEPFAR, the USG is to support the transfer of skills necessary to ensure that Zambians working within the health system and other related programs at the national, provincial and district levels have the capacity to build and manage their health systems. The USG is to also actively inform and support the policy dialogue around HIV and AIDS to ensure that evidence-based policies are adopted and utilized to strengthen the national platform for broad based change in HIV and AIDS programming—see Appendix 5 Objectives, Key Program Components and Outcome Results.

8.4 Specific GRZ Expected Contributions

Provide national leadership for and coordination of the multisector response to HIV and AIDS;

Mobilize government ministries to support the national HIV and AIDS program and provide required resources to ensure ownership of the program via the MOH, NAC and line ministries;

Lead program implementation through provision of HIV related health services in public facilities. Coordinate focus service delivery areas including prevention of new infections, treatment care and support, impact mitigation (OVC, vulnerable households, communities and individuals), and response management (policy, coordination and management, gender, monitoring and evaluation (M&E) and research);

Development of and support for public-private partnerships (PPPs) in order to enhance the national and local framework for action;

Lead and (in partnership with other donors) resource the systems strengthening agenda as laid out in the NASF 2011-2015; and

Provide leadership to the policy and legislative agenda for HIV and AIDS—see Annex 6 Policy Engagement.

8.5 Specific USG Expected Contributions

Work with the GRZ to prioritize and align investments as per the aforementioned objectives;

Support GRZ leadership in the health and development sector in the country;

Subscribe to the “Three Ones” and assist the GRZ and other partners to realize stated objectives and to mobilize technical support and the resources necessary for an effective HIV and AIDS response;

Work with the GRZ to prioritize investments in each of these service delivery areas to respond to requirements for Congressional earmarks such as the 10 percent of annual PEPFAR resources for OVC services;

Develop and support PPPs to enhance the national and local framework for action;

Support the transfer of skills necessary to ensure that Zambians working within the health system and other related programs at the national, provincial and district levels have the capacity to build and manage their health systems;

Actively inform and support the policy dialogue around HIV and AIDS to ensure that evidence-based policies are adopted and utilized to strengthen the national platform for broad based change in HIV and AIDS programming—see Appendix 7 Projected GRZ and USG Contributions by Objective.

9. Management

Management for the implementation of the Partnership Framework includes the following levels of oversight:

9.1 High Level GRZ-USG oversight of the Partnership Framework is to be provided through annual joint meetings convened by the Minister of Health, in consultation with the Minister of Finance and National Planning and the U.S. Ambassador to Zambia. These meetings are to coincide with the hosting of existing review structures, such as the Health Joint Annual Review (JAR) and/or the HIV Joint Annual Program Review (JAPR).

9.2 Strategic Oversight: The Partnership Framework is to be coordinated by existing in-country mechanisms such as the HIV and AIDS and Health Sector Advisory Groups (SAGs) and Cooperating Partner groups on HIV and AIDS and Health. It is expected that the MOH and NAC would continue to hold HIV and AIDS and Health SAG meetings semi-annually or more regularly in order to ensure oversight and implementation of the national plans, the Partnership Framework and the Partnership Framework Implementation Plan.

9.3 Technical Oversight: The Partnership Framework is to be coordinated by existing in-country mechanisms, including MOH and NAC thematic groups which are aligned with the objectives covered in the NASF2011-2015 and NHSP 2011-2015. It is intended that a joint M&E plan for the Partnership Framework be developed and evaluated through the use of the existing GRZ and USG complementary M&E systems. These are to be further elaborated through the NASF 2011-2015 and the NHSP 2011-2015 and codified in the Partnership Framework Implementation Plan.

9.4 With the NASF 2011-2015 and the NHSP 2011-2015 in place, the health sector in Zambia is promoting a comprehensive approach to planning and budgeting, financial management and accounting, procurement and performance monitoring of the sector using agreed indicators of progress to meet targets and outputs. Reporting is to be based on performance indicators defined as part of the health sector performance framework presented in the NASF 2011-2015.

9.5 The USG is to harmonize activities with relevant Government priorities and work with GRZ ministries, institutions and partners to advance the HIV and AIDS agenda in Zambia.

9.6 The GRZ promotes donor coordination through the SAGs which are convened at least on a semi-annual basis and led by the GRZ. SAG members include Cooperating Partners, civil society, NGOs, universities, private sector entities and other interested parties including foundations. Cooperating Partners are invited to attend all SAGs and in the HIV and AIDS sector are represented by a troika which is currently comprised of USG, Ireland and the Joint United Nations Program on HIV/AIDS (UNAIDS). Other Cooperating Partners participating in the HIV group include: Canada, European Union, Germany, Japan, the Netherlands, Norway, Sweden, the United Kingdom and members of the UN family. In addition to the SAG meetings, the Cooperating Partners group on HIV and AIDS meets on a monthly basis, with alternate months being a joint meeting between the partners and the NAC. This meeting is co-chaired by NAC and the troika.

10. Funding

10.1 The USG, via PEPFAR, and the Global Fund for AIDS, TB and Malaria (GFATM) are the major sources of external funding in Zambia for HIV and AIDS programming. The Joint Financing Arrangement (JFA)[7], to which PEPFAR contributes, provides direct budget support to the NAC to coordinate the multisectoral response. In addition, the USG currently has 13 direct cooperative agreements with the GRZ and parastatal organizations that directly support implementation of HIV and AIDS programs throughout the nation. These types of support are to continue through this Partnership Framework, along with continued direct program implementation in support of joint objectives.

10.2 The GRZ is to work with the USG and other Cooperating Partners to identify more sustainable funding structures to continue the national HIV and AIDS response into the future.

11. Performance Monitoring and Evaluation

11.1 Monitoring the Partnership Framework is to be done through existing systems, including the Ministry of Health’s JAR and the NAC’s JAPR that assess progress towards targets, commitments, achieving cost efficiencies through coordinated financing, increasing program ownership by the partner country, and steps to allow for mid-course corrections, as needed, to ensure achievement of stated goals and objectives.

11.2 Negotiated quantified annual performance targets are to be included in the Partnership Framework Implementation Plan and should correspond to those found in the NASFNOP 2011-2013. The planned contributions of each of the partners to the overall financing of the HIV response (and revised five-year targets as necessary) also are to be outlined in the Partnership Framework Implementation Plan.

12. Modifications

Partners to this Partnership Framework are to annually review and discuss the implementation, application and effectiveness of the procedures and priorities outlined in this Partnership Framework. Any modifications to the terms of this Partnership Framework may be made only through the written concurrence of the Partners.

13. Dispute Settlement

Any dispute between the Partners arising from implementation or interpretation of the Partnership Framework is to be settled amicably through consultation and negotiation between the GRZ and USG.

14. Appendices

The attached appendices 1-7 provide additional information and clarity to the document and are an integral part of this Partnership Framework.

15. Partnership Framework Coming Into Effect

This Partnership Framework is to become effective on the date it is signed by the GRZ and USG representatives.

Appendix 1. Background

In 2008, PEPFAR reauthorization called for the development of Partnership Frameworks that lay out a five-year coordinated response for HIV and AIDS programming among PEPFAR country governments, the USG and other partners. Partnership Frameworks are designed to support governments to realize health sector and HIV and AIDS goals and objectives through technical assistance and support for service delivery, policy reform and coordinated financial commitments; and to promote government ownership and capacity for a sustainable response to the HIV and AIDS epidemic. Each Partnership Framework is complemented by a Partnership Framework Implementation Plan that spells out in more detail the five-year objectives, contributions and targets for the Framework.

HIV and AIDS is one of the greatest threats to sustainable human development in Zambia. The epidemic in Zambia is set against a backdrop of pervasive poverty. Zambia has one of the highest incidences of poverty in the world with 68 percent of the population living in poverty (UNDP, Zambia Human Development Report (ZHDR), 2006). HIV and AIDS is undermining national capacity to build sustainable productivity while, at the same time, threatening and destroying household livelihoods. HIV and AIDS reinforce poverty while poverty in turn makes people susceptible to HIV and AIDS. The 2007 ZHDR advocates that responding to HIV and AIDS is fundamental for Zambia to make progress in human development.

In response to GRZ economic development and health sector priorities, this Partnership Framework provides a five-year strategic agenda between the GRZ, the USG, Cooperating Partners and others for the national response to HIV and AIDS. The Partnership Framework supports progress towards achievement of the goals articulated in the Sixth National Development Plan2011- 2015 (SNDP) and associated sectoral strategies and frameworks. The SNDP provides the development framework for the country to meet “aspirations” laid out in the National Long Term Vision 2030, Zambia’s Human Development Index and Zambia’s Millennium Development Goals (MDGs) and “provides a broader picture of national priorities and programmes for the next five years ((draft)SNDP 2011-2015, p. 8).”

The stated health sector goal in the SNDP is “to improve the health status of people in Zambia in order to contribute to socio-economic development.” The supporting strategic focus is “to provide equitable access to quality health services.”

In Zambia, the national response to the HIV epidemic is coordinated by the NAC. The NAC Director General reports to the Cabinet Committee of Ministers on HIV and AIDS which is chaired by the Minister of Health who reports directly to the President of the Republic of Zambia. Together NAC and the MOH lead the charge towards mitigating the impact of HIV and AIDS and fostering a nation free from the threat of AIDS.

Appendix 2. The HIV Epidemic in Zambia

Among Zambian adults aged 15 – 49; current HIV prevalence is 14.3 percent[8], a slight decline from the 15.6 percent[9] prevalence reported in the 2001/2002 Zambia Demographic and Health Survey (2001/2002 ZDHS). The epidemic in Zambia is dramatically gender-based with 16 percent of women aged 15-49 HIV positive compared to 12 percent of men aged 15-49 HIV positive. Overall, HIV prevalence in urban areas is twice as high as in rural areas (20 and 10 percent, respectively). Among women, aged 15-49, the HIV prevalence rate in urban areas is more than twice as high as in rural areas (23 and 11 percent, respectively). The same is true for men where those living in urban areas have an HIV prevalence rate of 16 percent compared with 9 percent in rural areas. In Zambia, HIV prevalence increases with level of education and wealth. From 2001/2002 - 2007, adult HIV prevalence increased in three of nine provinces by an average of 2.1 percent. Prevalence remains high among sex workers (65 percent) and within the military in Zambia (24-30 percent[10]).

Data from the 2006 Antenatal Care Surveillance Survey (2006 ANCSS) and the 2007 DHS highlight six key drivers of the HIV/ AIDS epidemic in Zambia. These are: 1) high rates of multiple and concurrent partnerships (MCP); 2) low and inconsistent condom use; 3) low rates of male circumcision (MC); 4) population mobility; 5) vulnerable groups with high risk behaviors; and 6) mother to child transmission (MTCT). In addition, other factors such as gender inequality, income disparity, socio-cultural practices, and stigma interact with the drivers to sustain high levels of risk and vulnerability.

The 2009 Zambia HIV Prevention Response and Modes of Transmission Analysis describes Zambia’s significant success in scaling up access to ART leading to an increase in the percentage of HIV positive-eligible clients accessing ARVs from 33 percent in 2006 to 79 percent in 2009. Prevention programs have also been scaled up including the number of TC centers, and PMTCT centers. Despite these prevention efforts, however, the number of new infections remains high with an estimated 82,681 adults newly infected in 2009.

Gender inequalities, perpetuated by male behavior and dominance are deeply enshrined in Zambian culture through socialization processes which begin at an early age. Due to an imbalance of power relations in favor of men and a resulting lack of self-assertiveness in sexual relations, women face a higher risk of HIV and other sexually transmitted infections (STIs) than men. The exposure is further reinforced by gender-based violence (GBV), primarily perpetrated by male members of the household. GBV also constrains access to testing and counseling as well as treatment for women in abusive relationships.

Zambia is home to over 800,000 OVC 0-17 years of age due to AIDS.[11] Of households sampled, the 2007 DHS found that four in ten children under age 18 were not living with both parents; and that 15 percent of children under age 18 were orphaned—one or both parents were dead. Children living with chronically ill parents or caregivers experience significant hardships as serious illnesses limit the availability of household resources to feed, clothe and educate them. These children are also at greater risk of dropping out of school due to the inability to pay school fees, the need to help with household chores, and to stay at home to care for sick parent/s or younger siblings. Children who have lost both parents are more likely to drop out of school than children with both parents or even one parent alive.

It is estimated today that there are over one million Zambians living with HIV and AIDS. Many of these individuals receive ART and are also excellent candidates for interventions targeting prevention with positives (PWP). While HIV is mostly a female and urban phenomenon, its impact continues to infiltrate rural populations. While access to treatment has improved, it is still estimated that over 75,000 Zambians die from HIV annually. Greater efforts in prevention and treatment are paramount if Zambia is to decrease the incidence of HIV in the coming years.

Appendix 3. Developing the Partnership Framework Implementation Plan

To develop the Partnership Framework Implementation Plan, GRZ and USG meetings are to occur to discuss the process to collaboratively develop and draft the Partnership Framework Implementation Plan. Upon approval of the Partnership Framework, a series of stakeholder briefings are to be conducted to support the development of the Implementation Plan. These briefings may take place with the following:

National HIV/AIDS/STI/TB Council;

Ministries of Health, Agriculture; Community Development and Social Services; Youth, Sport, and Child Development, Defense, Finance and National Planning; Education; Health; Justice; Labor and Social Services; Local Government and Housing; Home Affairs; Gender in Development Division; and the President’s Cabinet Committee of Ministers on HIV and AIDS;

Relevant Parliamentary Committees (Health, Finance);

Donors and Cooperating Partners; and

Other non-governmental and civil society organizations including those directly involved in HIV and AIDS prevention, treatment and care, OVC support, GBV prevention and management and gender integration into HIV and AIDS programs.

The Partnership Framework Implementation Plan is to be presented to and confirmed at the GRZ Permanent Secretary or designates level and with the USG PEPFAR Country Coordinator.

Appendix 4. The National Response

The Sixth National Development Plan 2011-2015

The GRZ, through the Ministry of Finance and National Planning, is finalizing the SNDP 2011-2015 which is a successor to the Fifth National Development Plan (FNDP) 2006 – 2010. In an effort to build on successes and address the challenges identified during the FNDP, the GRZ seeks to attain the following overarching objectives:

1. To accelerate economic growth, infrastructure development and diversification;

2. To promote rural investment and accelerate poverty reduction; and

3. To enhance human development.

The strategic focus of the SNDP is therefore to address the binding constraints of infrastructure and human development. In pursuing the above objectives and the strategic focus, the SNDP also integrates major cross cutting issues such as HIV and AIDS, disability, gender, climate change and environment.

The SNDP provides the macro structure under which individual sectors develop implementation plans or frameworks. For the health sector, this includes the National HIV and AIDS Strategic Framework (NASF) 2011-2015 and related National Multisectoral HIV and AIDS Program Operational Plan (NOP) and the National Health Strategic Plan (NHSP) 2011-2015.

The National HIV and AIDS Strategic Framework 2011-2015

The NASF 2011-2015 provides strategic policy and technical orientation for the implementation of Zambia’s multisectoral and decentralized HIV and AIDS program. By aligning the NASF 2011-2015 with other national strategic frameworks such as Vision 2030, the SNDP 2011-2015, The Poverty Reduction Strategy and TheGender Plan of Action, the national HIV and AIDS response is anchored in the wider socioeconomic development of the country. It is also anticipated that successful implementation of the NASF 2011-2015 would contribute to the attainment of the MDGs.

The framework is evidence-based and incorporates gender and human rights dimensions to ensure accelerated implementation of universal access to HIV and AIDS services. To ensure a sustained gender sensitive response, an integrated gender-based analysis of the epidemic drivers and other structural factors (gender inequality, poverty, income disparities) was incorporated in the current NASF. At the same time, the NASF mainstreams human rights to promote the protection of basic rights especially among people living with HIV and AIDS (PLHA), OVC and other vulnerable groups including women, girls and people with disabilities. Areas of focus include protection from stigma and discrimination, the right to privacy (protecting people from mandatory testing, confidentiality of information), the right to education and information, and access to services.

In the NASF 2011-2015, Zambia has articulated four national priorities for the multisectoral HIV and AIDS response:

To accelerate and intensify prevention in order to reduce the annual rate of new HIV infections

To accelerate the provision of universal access to comprehensive and quality treatment, care and support for people living with HIV and AIDS, their caregivers and their families, including services for TB, STIs and other opportunistic infections

To mitigate the socio-economic impacts of HIV and AIDS especially among the most vulnerable groups, OVC, PLHA and their caregivers and families

To strengthen the capacity for a well coordinated and sustainably managed HIV and AIDS multisectoral response

These four national priorities, plus an additional priority taken from the National Health Strategic Plan (NHSP) 2011-2015—To strengthen the systems which underpin Zambia’s response to HIV and AIDS—form the five major objectives of this Partnership Framework and the Partnership Framework Implementation Plan.

The National Health Strategic Plan 2011-2015

In the 2030 Vision, Zambia reaffirmed its commitment to achieving the MDGs. The MDGs overlap with both the SNDP and the NHSP 2011-2015 and are fully consistent with Zambia’s national priorities for economic growth and sustainable development. With a focus on the attainment of the health-related MDGs, the NHSP 2011-2015 is based on the World Health Organization’s (WHO) six building blocks for health systems[12] with the addition of a seventh section on infrastructure as a framework for planning and priority setting.

Within this framework, the MOH mission is “to provide equitable access to cost effective, quality health services as close to the family as possible.” The key principles for the implementation of the NHSP2011-2015 are equity of access, universal coverage, affordability, cost-effectiveness, accountability, partnerships; and decentralization and leadership.

Zambia’s diverse HIV epidemic makes the Decentralization Policy (2003) and Implementation Plan (2009), and community and health systems strengthening especially important. Structures at decentralized levels have been put in place to coordinate the local response to HIV and AIDS and broader health services.

Figure 1 below illustrates the conceptual framework for the coordination of the multisectoral HIV and AIDS response in Zambia. Work is ongoing to establish and develop the corresponding structures in keeping with the Decentralization Policy, and also among civil society and private sector networks.

Appendix 5. Objectives, Key Program Components and Outcome Results

The vision, goal and impact level results are to be achieved through the following five major objectives and key programmatic sub-objectives as taken from the NASF2011-2015 and NHSP 2011-2015.

1) To accelerate and intensify prevention in order to reduce the annual rate of new HIV infections

Intensify and accelerate prevention of sexual transmission, addressing the key drivers of the epidemic through targeted communication and mobilization for social and behavior change which emphasizes the gender dimension and clinical interventions

Key components of the prevention response include activities for targeted communication for behavioral and social change with attention to structural and proximal drivers of the epidemic, including MCP; scaled-up MC services; improved condom availability; scaled-up prevention activities for youth; improved STI prevention and treatment services; improved programs that address the role of alcohol and substance abuse; increasingly integrated services, with special attention to PWP programs; and a package of prevention interventions for mobile populations and vulnerable groups

Prevent family transmission of HIV including MTCT

Key components include strengthening commitment and leadership for full coverage of pediatric HIV prevention, care and support services; integration of pediatric HIV prevention, care and support services into maternal, newborn and child health (MNCH) services; promoting and supporting comprehensive health systems interventions to improve the delivery of HIV prevention, care and treatment services for women and children

Integrate prevention in all aspects of care at all healthcare settings

Key components include reviewing the capacity of blood testing laboratories; developing a follow up and referral system for blood donors who test HIV positive; and ensuring the staff, equipment and supplies are in place to maintain blood screening quality and safety

Young females and males aged 15-24 who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV increased from 35% in 2007 to 50% in 2013 and 65% by 2015

Fewer persons have multiple and concurrent partnerships (MCP)

Females and males aged 15-49 who had multiple and concurrent partnerships in the last 12 months is reduced from 1.2% for females and 14% for males in 2007 to less than 1% for females and remains that way by 2015, and to 10% by 2013 for males and to 5% by 2015

Reduction in HIV infection among females 15-49

Among females aged 15-49, HIV infection is reduced from 16% in 2009 to 10% in 2013 and to below 8% by 2015

HIV Counseling and Testing

More people test for HIV and know their results

Females and males aged 15-49 who received an HIV test in the last 12 months and know their results is increased from 15.4% in 2008 to 30% in 2013 and 50% by 2015

Condom Promotion

More people consistently and correctly use condoms in their last sexual intercourse

Females and males aged 15–49 who had more than one partner in the past 12 months who used a condom during their last sexual intercourse increased from 37% for females and 50% for males in 2007 to 45% for females and to 60% for males in 2013 and 55% for females and 70% for males by 2015

Male Circumcision

More males are circumcised by a health professional

Males aged 15-49 years circumcised as part of the minimum package of MC for HIV prevention services increased from 13% (65,000) in 2007 to 30% (150,000) in 2013 and 50% (300,000) by 2015

HIV positive pregnant females who receive ART to reduce the risk of MTCT is increased from 61% (47,175) in 2009 to 85% (72,828) in 2013 and to 95% (85,655) in 2015

The number of HIV infected infants as a result of mother to child transmission is reduced

Infants born to HIV infected mothers who are infected is reduced from 7% in 2009 to 5% in 2013 and to less than 2% by 2015

Post Exposure Prophylaxis

All persons who have been accidentally or forcibly exposed to HIV are given drugs to reduce the risk of primary infection

People in need of PEP provided with PEP in accordance with national guidelines in the last 12 months remains at 100% in 2013 and 2015

Sexually Transmitted Infections

Fewer females and males have STIs

Females and males who report having a STI in the past 12 months has reduced for females from 34% in 2007 to 17% in 2013 and to 5% in 2015; and for males from 26% 2007 to 13% in 2013 and 5% in 2015

Blood Safety

Donated blood units are screened for HIV and other transfusion transmissible infections (TTIs) in a quality assured manner

Facilities with donated blood units that have been screened for HIV and TTIs using national testing guidelines are maintained at 100%[13] between 2010 and 2015

2) To accelerate the provision of universal access to comprehensive and quality treatment, care and support for people living with HIV and AIDS, their caregivers and their families, including services for tuberculosis (TB), STIs and other opportunistic infections (OIs)

Support universal access to quality ART and comprehensive care and treatment (CCT) services

Key components include providing ART for all PLHA who meet the criteria (CD4 count of 350 or below); strengthening drug procurement and logistics capacity to ensure delivery and availability of ARVs; providing nutrition support for malnourished PLHA, children and infants; facilitating a single entry system for counseling, diagnosis, treatment and follow up for HIV and TB patients; patient tracking systems; and strengthening community systems to support HIV, AIDS and TB care and support

Expansion of treatment for TB/STIs/OIs including HIV-related cancers by ensuring that better drugs are available to treat and prevent common opportunistic infections and support palliative care

Key components include strengthening community participation and support to TB and HIV activities to track treatment defaulters and strengthen treatment literacy; expanding TB screening in CT services; enrolling TB patients on ART if necessary; and strengthening the provision of provider initiated CT for HIV to all TB patients

Foster greater linkages between TB and HIV activities for cross testing and treatment

Procure and supply HBC kits

Continue to promote the use of pain management protocols for PLHA

Outcome Results by 2015:

Antiretroviral Therapy

More PLHA survive longer on ART

HIV positive adults (15 and older) still alive 12 months after the initiation of ART increased for adults from 90% in 2010; to 98% in 2013; and to 98% in 2015

HIV positive children (0-14 years) still alive 12 months after the initiative of ART increased from 80% in 2010; to 90% in 2013; and to 95% by 2015

TB/HIV Co-Infection

More PLHA with TB/HIV co-infection are successfully treated

PLHIV with new smear-positive TB who have been successfully treated increased from 41% in 2007 and 60 % in 2013 and to 75% by 2015

Community and Home Based Palliative Care Services

More people receive comprehensive and quality care at home and in the community

Households that received certain free basic external support to care for family member/s aged 15-59 years in the last year increased from 41%[14] in 2009 to 50% in 2013 and 60% by 2015

(Households that are eligible for support have family member/s who have been very sick or who died within the past 12 months after being very sick)

3) To mitigate the socio-economic impact of HIV and AIDS especially among the most vulnerable groups orphans and vulnerable children, PLHA and their caregivers/families

Protect and provide support for OVC

Key components include providing in and out-of-school youth with life-skills based HIV education; implementation of the social protection strategy that includes medical, emotional and social/material support for households caring for OVC; sensitize community leaders to promote post-basic education for girls; and strengthen community systems to monitor child welfare practices and to establish systems to protect children from exploitation and sexual abuse

Address stigma and discrimination through structural and community measures

Key components include community education and awareness programs that include age-appropriate information on HIV, life skills, RH, gender equality, non-violence against women and girls and HIV-related tolerance and non-discrimination

Promote food security and income/livelihood generation programs for PLHA and their caregivers/families

Key components include supporting the identification and implementation of sustainable livelihoods; promoting equitable access to productive assets (land, equipment, credit, skills training); provide food and material support to incapacitated and vulnerable households; prioritize food assistance to food insecure households with chronically ill adults and children; and provide social protection to males and females made vulnerable from the effects of HIV and AIDS

Key Enabling Activities:

Continue to support the establishment of integrated structures which respond to issues pertaining to OVC

Identify opportunities for potential direct support to ministries tasked with leading the OVC response

Foster public/private partnerships with businesses and other communities to provide economic opportunities for older vulnerable children

Outcome Results by 2015:

Vulnerable Households and Communities

More people receive comprehensive and quality care at home and in the community

Males and females 18-59 years who have been either very sick or who died within the past 12 months after being very sick whose households received free basic external support to care for them within the last year is increased from 41% in 2009 to 50% in 2013 and to 60% by 2015[15]

Orphans and Vulnerable Children

More OVC receive free external basic support

OVC under 18 years whose households received at least one type of free basic external support (medical, emotional and social/material and school related) to care for the child in the last 12 months is increased from 15.7% in 2009 to 25% in 2013 and to 50% by 2015

4) To strengthen the systems which underpin Zambia’s response to HIV and AIDS

Key components include implement accountable, efficient and transparent management systems at all levels of the health sector; ensure availability and access to essential HIV and AIDS-related health commodities for clients and service providers; upgrade laboratories to ensure accurate HIV, TB and STI testing and diagnosis including the procurement and maintenance of laboratory equipment and supplies and laboratory personnel training; ensure availability of adequate, appropriate and well-maintained HIV and AIDS-related medical equipment and accessories; provide sustainable infrastructure conducive for delivery of quality HIV and AIDS-related health services; and support the strengthening of health information systems that include a robust national electronic medical record system

Community systems strengthening

Key components include building meaningful community engagement and participation in HIV and AIDS services and programs; building leadership and governance, community organization, resource mobilization, advocacy, and monitoring and resource management

Strengthening the capacity of civil society organizations

Key components include engaging CSOs in community capacity building activities; linking CSOs to capacity development activities provided through umbrella organizations such as the Zambia National AIDS Network; providing training in financial planning and management, advocacy and networking, and human resource capacity development

Key Enabling Activities:

Continue to identify and implement strategies to mitigate human resource shortages such as training nurses to prescribe ARVs

Explore retention schemes for health workers

Support district level monitoring and evaluation training for personnel involved in record keeping and data reporting

Strengthen logistics systems to ensure the right commodities are delivered to the right places at the right times

Outcome Results by 2015:

Health Sector Financing

Increased government budget support to the district level

The Ministry of Health releases to the districts as a percentage of the non personnel emoluments government domestic budget increases to at least 14 percent.[16]

MoH Management and Fiscal Performance

Improved MoH program and financial management and performance

The Ministry of Health has acted upon at least 85 percent of recommendations raised in the Auditor General’s report.[17]

Human Resources for Health

Health center staffing increased

The number of health centers with at least one qualified health professional increases to 100 percent by 2015.[18]

5) To strengthen the capacity for a well coordinated and sustainably managed HIV and AIDS multisectoral response including:

Enhance resourcing of a sustained national response based on the Joint Annual Financing Review

Key components include advocacy to increase the level of domestic funding and to encourage Cooperating Partners to at least maintain their current levels of funding and increase their contributions to facilitate the scale up of HIV and AIDS activities; strengthen capacity for resource mobilization, disbursement and accountability

Streamline and align the HIV and AIDS institutional arrangements in line with Zambia’s Decentralization Policy and the Decentralization Implementation Plan

Key components include the coordination of NGOs and the private sector through umbrella organizations; developing and supporting partner coordination through existing structures such as UNAIDS; strengthening the capacity of NAC to provide leadership for the national response through development of a strategic plan and improvement of institutional reporting mechanisms; and strengthening capacity at the provincial and district level to plan and manage the HIV and AIDS response at that level

Build an enabling policy and legal environment

Key components include developing institutional capacity to advocate for effective rights-based policy implementation; and strengthening the use of evidence in advocacy and application of data in policy development

Mainstream gender and human rights across sectors

Key components include conducting HIV-related socioeconomic assessments to examine the differential impact of HIV on females and males; advocate and implement a robust HIV monitoring and surveillance systems to effectively track HIV infection by gender, age and patterns of sera-discordance in couples; assess the legal and policy framework affecting males and females; develop qualitative and quantitative indicators to assess the impact of gender-specific interventions and gender mainstreaming in national HIV and AIDS and other development strategies

Other components specific to human rights mainstreaming include utilizing the Code of HIV and AIDS and Human Rights to advocate to eliminate stigma and discrimination associated with HIV and AIDS, to promote the right to privacy (protecting people from mandatory testing, confidentiality of information), the right to education and to access to services

Key Enabling Activities:

Support the movement to a more decentralized response to HIV and AIDS

Advocate for sustainable health sector financing schemes

Promote quality research to expand the evidence base for policy development

Integrate principles of gender and human rights mainstreaming into all HIV and AIDS program activities

Work with HIV and AIDS program managers and health workers to understand and implement equitable service delivery

Support gender awareness programming at the provincial and district levels to build their capacity to identify and respond to gender-related issues in HIV and AIDS

Outcome Results by 2015:

Enabling Policy and Legal Environment

The enabling policy and legal environment improved

Between 2011 and 2015 the enabling policy and legal environment necessary for the implementation of the national multisectoral response to HIV and AIDS is adequately strengthened[19]

Improved Coordination and Management

Effective coordination and management of the response

Between 2011 and 2015, 100% of all public and private sectors, partners, provinces, districts and communities are coordinating and managing the implementation of the national response at their level in line with the NASF 2011-2015

Gender and Human Rights Mainstreaming

HIV and AIDS and gender and human rights mainstreamed in policies, budgets and plans

Sectors that have mainstreamed HIV and AIDS, gender and human rights in sectoral policies, budgets and operational plans is increased to 50% by 2013 and to 100% by 2015

Capacity Development and Systems Strengthening

Stakeholder capacity strengthened

Stakeholder capacity to implement the NASF is strengthened by 2013 and remains the same by 2015

Appendix 6. Policy Engagement

Achieving outlined objectives is predicated on creating an increasingly supportive policy environment characterized by robust national and sector-specific policies together with realistic frameworks and strategies for policy implementation. At a minimum, the following policies are to be addressed by the GRZ over the course of the Partnership Framework to create a maximally supportive environment for the ascribed response to HIV and the systems that are needed to implement and sustain that response:

2. To accelerate the provision of universal access to comprehensive and quality treatment, care and support for people living with HIV and AIDS, their caregivers and their families, including services for TB, STIs and other opportunistic infections

2.1 Provide universal access to ART and CCT

2.2 Expand treatment for TB/STIs/OI including HIV related cancers

2.3 Strengthen HBC and CBC and provide access to palliative care

2.1.1 Continue to identify efficiencies and economies of scale to allow for expanded ART coverage

2.2.1 Continue to support the access and expansion of and linkages to TB, STI, OI and cancer services within appropriate settings and within USG guidelines

2.3.1 Continue to promote prevention with positives services, including care and nutritional support as appropriate

2.4.1 Continue supporting gender based interventions aimed at reducing the burden of care placed on women

2.3 With other partners, decide on a treatment scale-up trajectory which can be supported by existing and/or expected funding scenarios

2.3.1 Procure ARVs in line with projected needs and management distribution

2.3.2 Work to identify sustainable funding scenarios concomitant with scale-up plans and the burden of disease

2.3.3 Seek to maintain quality services and support based on GRZ’s current regimens

2.3.4 Identify opportunities to reduce the burden to care for PLHA disproportionately placed on women

UNITAID

GFATM

UNICEF

JICA: conduct ART expansion project in Southern Province

Clinton Foundation: support full treatment costs for all pediatric patients till end of 2011; support the revision of pediatric ART guidelines, roll-out and implementation

§ Follow-up on PWP programs; national policy, training and guidelines to identify priorities for the PFIP

3. Mitigation

Objective

Expected Contributions

Steps for Development of Partnership Framework Implementation Plan

Government of Zambia

(GRZ)

U.S. Government (USG)

Mutual GRZ-USG Actions

Support of other Partners

3. To mitigate the socio-economic impacts of HIV and AIDS especially among the most vulnerable groups, orphans and vulnerable children, PLHIV and their caregivers /families

3.1 Protect and provide support for orphans and vulnerable children

3.2 Address stigma and discrimination through structural and community measures

3.3 Promote food security and income/livelihood generation programs for PLHA and their caregivers/families

3.1.1 Continue to explore national advocacy structures advocate for children and support ongoing community activities for OVC including strengthening family/community-based responses

3.2.1 Continue to advocate for policies and practices supportive of PLHA

3.3.1 Promote linkages to and advocate for livelihoods activities including food security as they relate to PLHA

3.4.1 Continue supporting policies that address gender inequalities through social determinants; and continue supporting GBV services and the Justice system for GBV

[2] The target for 2015 is based on trend since 1995, using data from Human Development Report 2007/2008 UNDP, and African Development Bank Data

[3] It is anticipated that the achievement of this result would also contribute to the attainment of MDGs.

[4] This is in line with the concept of Virtual elimination of MTCT of HIV. The global target for virtual elimination is 5% at national level and 90% reduction in new infections between 2010 and 2015 [Source: Towards Universal Access to PMTCT – presentation to funders, May 10th 2010, UNAIDS]

[7] The JFA is a Joint Financing Arrangement led by the Danish Embassy at 36% of total funding. Other contributors are the Irish Embassy (26%), the Netherlands Embassy (15%), the Swedish Embassy (6%), the Norwegian Embassy and DFID (5%) and the USG (1%). The GRZ contributes 6% of the total JFA budget.

[15] Measured by households receiving medical, emotional and social/material support and PLHA who are clinically malnourished and who received nutritional support

[16] This indicator derives from Indicator HEA 4 in the Performance Assessment Framework 2008 – 2010 between the Ministry of Finance and National Planning at the Poverty Reduction Budget Support Cooperating Partners, 12 January 2009. The numerator is the releases of grants to district boards; the denominator is the non-personal emoluments MOH domestic budget. The target is extracted from the 2007 actual result, recognizing constraints that have occurred since development of the PAF.

[17] This indicator mirrors Indicator 4 in the Performance Assessment Framework 2008 – 2010 between Poverty Reduction Budget Support Cooperating Partners, 12 January 2009. 85% is the average across all ministries for responding to Office of the Auditor General recommendations, for this Partnership Framework, this indicator is specific to Ministry of Health recommendations.

[18] This indicator is derived from the Health Sector Performance Monitoring Matrix in the draft Health Chapter of the SNDP.

[19] Measured by the percent of national policies and legal instruments reviewed and incorporated into human and legal rights; and by reduced stigma in the general population around PLHA.